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This is VAERS ID 150155

Case Details

VAERS ID: 150155 (history)  
Form: Version 1.0  
Age: 74.0  
Sex: Male  
Location: Minnesota  
Vaccinated:1999-11-15
Onset:1999-11-20
   Days after vaccination:5
Submitted: 2000-03-08
   Days after onset:109
Entered: 2000-03-17
   Days after submission:9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / CONNAUGHT LABORATORIES U0163AA / UNK RA / IM

Administered by: Private       Purchased by: Private
Symptoms: Hallucination, Headache
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: B12 shot
Current Illness: NONE
Preexisting Conditions: hx of rectal incontinence, abdominal injuries, bilateral hearing loss, dementia, hypertension, degenerative joint disease, anemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Severe headaches, hallucinations, occasional confusion, short term memory loss, delusions, and paranoia of unclear duration. The pt also experienced loss of control of left foot. The pt experienced bleeding from the rectum (bright red). Annual FU: pt died. no other info provided.


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